Laparoscopic liver sectionectomy 2 and 3 (LLS 2 and 3): towards the "gold standard"

Early outcomes of single-port robotic left lateral sectionectomy in patients with hepatic tumor

Purpose

Laparoscopic left lateral sectionectomy (L-LLS) stands as a cornerstone procedure in hepatobiliary minimal surgery, frequently employed for various benign and malignant liver lesions. This study aimed to analyze the peri- and postoperative surgical outcomes of single-port robotic left lateral sectionectomy (SPR-LLS) vs. those of L-LLS in patients with hepatic tumors.

Methods

From January 2020 through June 2023, 12 patients underwent SPR-LLS. During the same period, 30 L-LLS procedures were performed. In total, 12 patients in the robotic group and 24 patients in the laparoscopic group were matched.

Results

When the SPR-LLS and L-LLS groups were compared, the operation time was longer in the SPR-LLS group with less blood loss and shorter hospital stay. Postoperative complications were observed in 3 patients in the L-LLS group (12.5%) and 1 patient in the SPR-LLS group (8.3%).

Conclusion

SPR-LLS using the da Vinci SP system was comparable to laparoscopic LLS in terms of surgical outcomes. SPR-LLS was associated with lower blood loss and less postoperative length of stay compared to L-LLS. These findings suggest that left lateral sectionectomy is technically feasible and safe with the da Vinci SP system in select patients.

An Ex Situ Cadaver Liver Training Model Continuously Pressurized to Simulate Specific Skills Involved in Laparoscopic Liver Resection: the Lap-Liver Trainer

BACKGROUND

Laparoscopic liver resection (LLR) requires delicate skills. The aim of the study was to develop a training model mimicking as much as possible intraoperative bleeding and bile leakage during LLR. We also assessed the educational value of the training model.

METHODS

The Lap-liver trainer (LLT) combined a continuously pressurized ex situ cadaver liver and a customized mannequin. The customized mannequin was designed by computer-aided design and manufactured by 3D printing. The left lateral sectionectomy (LLS) was chosen to assess the feasibility of a LLR with the LLT. Eighteen volunteers were recruited to perform LLS and to assess the educational value of the LLT using a Likert scale.

RESULTS

The customized mannequin consisted of a close laparoscopic training device based on a simplified reconstruction of the abdominal cavity in laparoscopic conditions. Ex situ cadaver livers were pressurized to simulate blood and bile supplies. Each expert surgeon (n = 3) performed two LLS. They were highly satisfied of simulation conditions (4.80 ± 0.45) and strongly recommended that the LLT should be incorporated into a teaching program (5.00 ± 0.0). Eight novice and 4 intermediate surgeons completed a teaching program and performed a LLS. Overall, the level of satisfaction was high (4.92 ± 0.29), and performing such a procedure under simulation conditions benefited their learning and clinical practice (4.92 ± 0.29).

CONCLUSIONS

The LLT could provide better opportunities for trainees to acquire and practice LLR skills in a more realistic environment and to improve their ability to deal with specific events related to LLR.

Achievement of textbook outcomes and comparisons with benchmark values after laparoscopic left lateral sectionectomy

Laparoscopic left lateral sectionectomy (LLLS) is considered a standard approach for patients. Textbook outcomes (TOs) with benchmark values have been developed to help centers assess their outcomes of LLLS. The aim of our study was to identify factors associated with achieving TOs after LLLS. This is a retrospective cohort study including 195 patients undergoing LLLS between January 2004 and December 2018. Our outcomes were compared to benchmark values and graded as similar, better, or worse. A TO was achieved in 106 patients (54.4%). The main determinant for achieving a TO was prolonged hospital stay. Year of surgery [P = 0.002; odds ratio (OR) 3.913, 95% confidence interval (CI) 1.666-9.188], American Society of Anesthesiologists (ASA) score (P = 0.015; OR 0.104, 95% CI 0.017-0.650), body mass index (BMI) score (P = 0.075; OR 1.135, 95% CI 0.988-1.304), inflow clamping > 40 min (P = 0.037; OR 0.090, 95% CI 0.009-0.867) and operation time (P = 0.002; OR 0.991, 95% CI 0.985-0.997) were the factors associated with achieving a TO. Our outcomes were similar to the benchmark values for all criteria, except for the transfusion rate (our study vs benchmark values; 6.2% vs 3.8%), which was worse in our patients. We achieved better outcomes with a lower conversion rate (4.6% vs 7.2%), fewer patients requiring massive transfusion (4.1% vs 8.3%), lower rate of prolonged inflow clamping (3.9% vs 6.3%), lower overall complication rate (11.9% vs 19.8%), lower reoperation rate (0% vs 3.4%), and fewer patients with a positive margin (1.5% vs 10.8%). Year of surgery, ASA score, inflow clamping > 40 min and operation time were independently associated with failure to achieve a TO. TOs are useful tools to measure the surgical outcomes and compare surgical performance with benchmark values. TOs also offer a new method to retrospectively compare outcomes.

Standardized single-incision plus one-port laparoscopic left lateral sectionectomy: a safe alternative to the conventional procedure

Purpose

Laparoscopic left lateral sectionectomy (LLLS) is a feasible and safe procedure with a relatively smooth learning curve. However, single-incision LLLS requires extensive surgical experience and advanced techniques. The aim of this study is to report the standardized single-incision plus one-port LLLS (reduced port LLLS, RPLLLS) technique and evaluate its safety, feasibility, and effectiveness for junior surgeons.

Methods

Between January 2008 and November 2020, the clinical records of 49 patients who underwent LLLS, divided into the conventional LLLS (n = 37) and the RPLLLS group (n = 12), were retrospectively reviewed. The patient characteristics, pathologic results, and operative outcomes were evaluated.

Results

A history of previous abdominal surgery in the RPLLLS group was significantly high (56.8% vs. 91.7%, p = 0.552). Notably, junior surgeons performed 62.2% of the conventional LLLSs and 58.4% of the standardized RPLLLSs. There were no significant differences between the two groups in terms of median operative time (121.0 vs. 113.5, p = 0.387), median blood loss (13.0 vs. 8.5, p = 0.518), median length of hospital stays (7.0 vs. 7.0, p = 0.408), and morbidity rate (2.7% vs. 0%, p = 0.565), respectively.

Conclusion

This standardized RPLLLS is a feasible and safe alternative to conventional LLLS and may become the ideal training procedure for both junior surgeons and surgeons aiming to learn more complex procedures.

Comparison of robotic and laparoscopic liver resection in ordinary cases of left lateral sectionectomy

BACKGROUND

Laparoscopy was considered the standard method of left lateral sectionectomy. The robotic approach showed advantages in complex cases of left lateral sectionectomy. However, the impact of the robotic system on ordinary cases is still unknown.

METHODS

Retrospective review of consecutive robotic left lateral sectionectomy (R-LLS) and laparoscopic left lateral sectionectomy (L-LLS) from January 2015 to December 2019. Univariate and multivariate logistic regression was used to determine the effects of surgical method and surgical complexity on postoperative length of stay, surgical and overall cost.

RESULTS

258 consecutive patients who underwent minimally invasive left lateral sectionectomy were analyzed. L-LLS had comparable outcomes and decreased surgery (USD 2416.3 vs 4624.5; p < 0.001) and overall costs (USD 8004.5 vs 11897.1; p < 0.001) compared with R-LLS in the ordinary-case group, whereas R-LLS was associated with shorter postoperative LOS (5.0 vs 3.5 days; p = 0.004) in the complex-case group. On multivariable analysis, R-LLS was predictive of shorter postoperative LOS [odds ratio (OR) 0.388, 95% confidence interval (CI) 0.198-0.760, p = 0.006], whereas R-LLS was predictive of higher surgery (OR 65.640, 95% CI 17.406-247.535, p < 0.001) and overall costs (OR 102.233, 95% CI 22.241-469.931, p < 0.001).

CONCLUSION

Results of this study showed no clinical benefit to the R-LLS compared with L-LLS in ordinary cases. R-LLS had potential advantages in selected complex cases.

Level 2a evidence comparing robotic versus laparoscopic left lateral hepatic sectionectomy: a meta-analysis

OBJECTIVES

To evaluate comparative outcomes of robotic and laparoscopic left lateral hepatic sectionectomy (LLS).

METHODS

A systematic search of PubMed, Web of Science, EMBASE and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits was conducted. Overall, minor (Clavien-Dindo grade < III) and major (Clavien-Dindo grade > III) postoperative complications, mortality, volume of blood loss, conversion to an open procedure, procedure time, length of hospital stay, cost-effectiveness and R1 resection were the evaluated outcome measures.

RESULTS

Seven comparative observational studies reporting a total of 319 patients of whom 150 underwent robotic LLS and the remaining 169 patients underwent laparoscopic LLS were included. The robotic approach was associated with significantly longer procedure time (MD: 29.40 min, p = 0.01) and higher cost (MD: $4170, p < 0.00001) compared to the laparoscopic approach. There was no significant difference in overall postoperative morbidity (OR: 1.29, p = 0.62), Clavien-Dindo grade < III (OR: 1.65, p = 0.49), Clavien-Dindo grade > III (OR: 1.18, p = 0.85), perioperative mortality (RD: 0.00, p = 1.00), volume of blood loss (MD: 1.96 mls, p = 0.91), conversion to an open procedure (RD: - 0.02, p = 0.46), length of hospital stay (MD: 0.22 day, p = 0.52) or R1 resection (RD:0.00, p = 1.00) between two groups.

CONCLUSIONS

Meta-analysis of the best available evidence (level 2) demonstrated that robotic LLS is associated with significantly longer procedure time and higher cost and similar perioperative outcomes compared to the laparoscopic approach. Future randomised studies are required to evaluate short-term perioperative, long-term oncological and surgeon-centred outcomes.

Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS)

BACKGROUND

No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS).

METHODS

A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80.

RESULTS

A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19).

CONCLUSIONS

The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.

Safety and feasibility for laparoscopic versus open caudate lobe resection: a meta-analysis

BACKGROUND

Laparoscopic hepatectomy has been used widely due to its advantages as a minimally invasive surgery. However, multicenter, large-scale, population-based laparoscopic caudate lobe resection (LCLR) versus open caudate lobe resection (OCLR) has rarely been reported. We assessed the feasibility and safety of LCLR compared with OCLR using meta-analysis.

METHODS

Relevant literature was retrieved using PubMed, Embase, Cochrane, Ovid Medline, Web of Science, CNKI, and WanFang Med databases up to July 30th, 2020. Multiple parameters of feasibility and safety were compared between the treatment groups. Quality of studies was assessed with the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. Results are expressed as odds ratio (OD) or mean difference (MD) with 95% confidence interval (95% CI) for fixed- and random-effects models.

RESULTS

Seven studies with 237 patients were included in this meta-analysis. Compared with OCLR, the LCLR group had a lower intraoperative blood loss (MD - 180.84; 95% CI - 225.61 to - 136.07; P < 0.0001), shorter postoperative hospital stays (MD - 4.38; 95% CI - 7.07 to - 1.7; P = 0.001), shorter operative time (MD - 50.24; 95% CI - 78.57 to - 21.92; P = 0.0005), and lower rates in intraoperative blood transfusion (OR 0.12; P = 0.01). However, there were no statistically significant differences between LCLR and OCLR regarding hospital expenses (MD 0.92; P = 0.12), pedicle clamping (OR 1.57; P = 0.32), postoperative complications (OR 0.58; P = 0.15), bile leak (P = 0.88), ascites (P = 0.34), and incisional infection (P = 0.36).

CONCLUSIONS

LCLR has multiple advantages over OCLR, especially intraoperative blood loss and hospital stays. LCLR is a very useful technology and feasible choice in patients with caudate lobe lesions.

Long-term abdominal wall benefits of the laparoscopic approach in liver left lateral sectionectomy: a multicenter comparative study

BACKGROUND

Laparoscopy is nowadays considered as the standard approach for hepatic left lateral sectionectomy (LLS), but its value in the prevention of incisional hernia (IH) has not been demonstrated.

METHODS

Between 2012 and 2017, patients undergoing laparoscopic (LLLS) or open LLS (OLLS) in 8 centers were compared. Patients undergoing a simultaneous major abdominal procedure were excluded. The incidence of IH was assessed clinically and morphologically on computed tomography (CT) using inverse probability of treatment weighting (IPTW) and multivariable regression analysis.

RESULTS

After IPTW, 84 LLLS were compared to 48 OLLS. Compared to OLLS, LLLS patients had reduced blood loss (100 [IQR: 50-200] ml vs. 150 [IQR: 50-415] ml, p = 0.023) and shorter median hospital stay (5 [IQR: 4-7] days vs. 7 [6-9] days, p < 0.001), but experienced similar rate of postoperative complications (mean comprehensive complication index: 12 ± 19 after OLLS versus 13 ± 20 after LLLS, p = 0.968). Long-term radiological screening was performed with a median follow-up of 27.4 (12.1-44.9) months. There was no difference between the two groups in terms of clinically relevant IH (10.7% [n = 9] after LLLS, 8.3% [n = 4] after OLLS, p = 0.768). The rate of IH detected on computed tomography was lower after LLLS than after OLLS (11.9% [n = 10] versus 29.2% [n = 14], p = 0.013). On multivariable analysis, the laparoscopic approach was the only independent factor influencing the risk of morphological IH (OR = 0.290 [95% CI: 0.094-0.891], p = 0.031). The 2 preferential sites for specimen extraction after LLLS were Pfannenstiel and midline incisions, with rates of IH across the extraction site of 2.3% [n = 1/44] and 23.8% [n = 5/21], respectively (p = 0.011).

CONCLUSION

The laparoscopic approach for LLS decreases the risk of long-term IH as evidenced on morphological examinations, with limited clinical impact. Pfannenstiel's incision should be preferred to midline incision for specimen extraction after LLLS.

Learning Curve Under Proctorship of Pure Laparoscopic Living Donor Left Lateral Sectionectomy for Pediatric Transplantation

OBJECTIVE

To evaluate the learning curve of an expert liver transplantation surgeon approaching fully laparoscopic living donor left lateral sectionectomy (L-LLS) under proctorship.

BACKGROUND

Laparoscopic liver resections necessitate a long learning curve trough a stepwise fulfillment of difficulties. L-LLS requires expertise in both living donor liver transplantation and advanced laparoscopic liver surgery. There is currently no data about the learning curve of L-LLS.

METHODS

A total of 72 pure L-LLS were included in this study. A Broken line model was used to identify the periods of the learning curve. A CUSUM analysis of the operative time was performed to evaluate improvements of outcomes with time. To evaluate the relationship between operative time and progressive number of procedures, a linear regression model was applied. A receiver operating characteristic (ROC) curve was carried out to identify the cutoff for completion of the learning curve.

RESULTS

Operative time decreased with the progressive increase of procedures. Two cutoffs and 3 different periods were identified: cases 1 to 22, cases 23 to 55, and cases 56 to 72. A significant decrease in blood loss and operative time was noted. The CUSUM analysis showed an increase in operative time in the first period, a stable duration in the second period, and a decrease in the last. Blood loss was significantly associated with an increase in operative time (P = 0.003). According to the ROC curve, the learning curve was completed after 25 procedures.

CONCLUSIONS

L-LLS is a safe procedure that can be standardized and successfully taught to surgeons with large experience in donor hepatectomy through a proctored learning curve.

Single versus multiple port laparoscopic left lateral sectionectomy for hepatocellular carcinoma: A retrospective comparative study

BACKGROUND

Single port laparoscopic hepatectomy has been applied in some surgeries. We aimed to describe our experience with single port laparoscopic left lateral sectionectomy (SPLS) and to compare the safety and feasibility of this technique with those of conventional multi-port laparoscopic left lateral sectionectomy (MPLS) in the treatment of hepatocellular carcinoma (HCC).

METHODS

A total of 72 consecutive patients who underwent SPLS (n = 33) and MPLS (n = 39) for HCC were enrolled. The peri-operative parameters of safety and feasibility, as well as the short-term oncological outcomes were compared.

RESULTS

The length of postoperative hospital stay (LOS) was significantly shorter in the SPLS group than in the MPLS group (4.12 vs. 4.59 days, P = 0.043). No significant difference between the two groups was found in the operation time (104.58 vs. 95.69 min in the SPLS group and MPLS group respectively, P = 0.353) or the amount of blood loss (62.73 vs. 68.46 ml, P = 0.595). The 1-year recurrence-free survival rate was 77.9% in the SPLS group and 70.7% in the MPLS group (P = 0.82). Subgroup analysis showed that for patients without cirrhosis, the LOS was shorter in the SPLS group than in the MPLS group (P = 0.033), while for patients with cirrhosis, the LOS was not significantly different between the two groups (P = 0.201), although it was shorter in the SPLS group.

CONCLUSIONS

SPLS was a feasible and safe surgical approach for the treatment of HCC on left lateral section.

Single-Port Laparoscopic Surgery Is Feasible and Safe for Hepatic Left Lateral Sectionectomy for Benign Liver Lesions

Background and Objectives

The feasibility and safety of single-port laparoscopic surgery for left lateral liver lobectomy are largely unknown. This study is aimed at comparing the effectiveness and safety between single-port laparoscopic (SPL) and conventional multiport laparoscopic (CL) surgeries for hepatic left lateral sectionectomy.

Methods

A total of 65 patients receiving laparoscopic hepatic left lateral sectionectomy between January 2008 and July 2015 were included and divided into the SPL group (n = 40) and the CL group (n = 25).

Results

There was no significant difference in the operative time, estimated intraoperative blood loss, length of hospital stay, and incidences of postoperative complications (biliary leakage, hemorrhage, and contusion at incision) between groups (all P > 0.05). However, the SPL group had a significantly lower VAS pain score (at 24 h but not 7 days postoperation) and higher cosmetic satisfaction scores (at both 2 months and 6 months postoperation) than the CL group (all P < 0.01). Moreover, multivariate linear regression analysis further confirmed the superior pain score and cosmetic outcome in the SPL group.

Conclusions

Single-port laparoscopic hepatic left lateral sectionectomy is a safe and feasible treatment for patients with lesions in the left hepatic lobe. Patients with benign lesions in the left hepatic lobe are more suitable to receive single-port laparoscopic hepatic left lateral sectionectomy than those with malignancies.

Comparison study between open and laparoscopic liver resection in a Saudi tertiary center

Objectives:

To compare King Saud University Medical City experience in laparoscopic liver resection with our previously established database for open resections.

Methods:

A retrospective study was conducted at King Saud University Medical City, Riyadh, Saudi Arabia. All adult patients who underwent liver resection from 2006 to 2017 were included. Patients who had their procedure converted to open were excluded.

Results:

Among the 111 liver resections included, 22 (19.8%) were performed laparoscopically and 89 (80.1%) were performed using the open technique. Malignancy was the most common indication in both groups (78.5%). The mean operative time was 275 min (SD 92.2) in the laparoscopic group versus 315 min (SD 104.3) in the open group. Intraoperative blood transfusion was required in the laparoscopic (9%) and open groups (31.4%). The morbidity rate was 13.6% in the laparoscopic group and 31.4% in the open group, and the mortality rate was 0% in the laparoscopic group and 5.6% in the open group.

Conclusion:

Laparoscopic liver resection appears to be a safe technique and can be performed in various benign and malignant cases.

Laparoscopic hand-assisted liver resection for tumours in the left lateral section

Context:

The role of the laparoscopic left lateral sectionectomy (LLLS) is debatable, and Level-1 data are lacking.

Aims:

The aim of the study is to evaluate the feasibility and safety of this approach.

Settings and Design:

This was a retrospective study.

Subjects and Methods:

From 2007 to 2014, patients undergoing LLLS were identified from two institutions.

Statistical Analysis Used:

Continuous variables were compared between groups with Student's t-test or Mann–Whitney test, as appropriate by type of distribution. Categorical variables were compared with Chi-square or Fisher's exact test, depending on the number of observations.

Results:

Thirty-eight patients were included in the study. The mean age was 63.5 + 13 years (range, 31–89), and the mean number of tumours was 1.7 + 1.5. Eleven (29%) patients underwent LLS combined with an additional liver resection (combined resections group). The mean duration of the operation and the mean estimated blood loss were significantly decreased in the LLS group compared to the combined resection group (101 + 71 min vs. 208 + 98 min and 216 + 217 ml vs. 450 + 223 ml; P < 0.05 for both, respectively). The major complications rate was 8% and no mortality occurred.

Conclusions:

In a subset of carefully selected cases, LLLS may provide the benefits of laparoscopy. This does not appear to compromise perioperative morbidity rates. We believe that this approach may serve as a training platform for surgical trainees.

Laparoscopic left lateral hepatic sectionectomy was expected to be the standard for the treatment of left hepatic lobe lesions: A meta-analysis

BACKGROUND

Laparoscopic left lateral hepatic sectionectomy (LLLHS) has been widely accepted because of the benefits of minimally invasive surgery. We aimed to assess the benefits and drawbacks of left lateral sectionectomy (of segments II/III) compared with laparoscopic and open approaches.

METHODS

Relevant literature was searched using the PubMed, Embase, Cochrane, and Ovid Medline databases. We calculated odds ratios or mean differences with 95% confidence intervals (CIs) for fixed-effects and random-effects models.

RESULTS

The meta-analysis included 14 trials involving 685 patients. There were no statistically significant differences between LLLHS and open LLHS (OLLHS) regarding analgesia (P = .31), pedicle clamping (P = .70), operative time (P = .54), hospital expenses (P = .64), postoperative alanine aminotransferase levels (P = .57), resection margin (95% CI -3.02-4.28; P = .73), or tumor recurrence (95% CI 0.51-3.05; P = .62). However, the LLLHS group showed significantly better results regarding blood transfusion (95% CI 0.14-0.73; P = .007), blood loss (95% CI -140.95 to -67.23; P <.001), total morbidity (95% CI 0.24-0.56; P <.01), and hospital stay (95% CI -3.84 to -2.31; P <.001) than the OLLHS group.

CONCLUSION

LLLHS has an advantage in the hospital stay, blood loss, and total morbidity. It is an ideal method for LLHS surgery.

An Improved Surgical Technique for Pure Laparoscopic Left Hemihepatectomy: Ten Years Experience in a Tertiary Center

Background: This study details our experience with an improved surgical technique involving the hepatic pedicle during laparoscopic left hemihepatectomy (LLH).

Methods: We describe an improved laparoscopic technique to extraparenchymally divide the left hepatic pedicle. A retrospective analysis of all of the patients who underwent laparoscopic liver procedures between 2002 and 2012 was conducted. The patients were divided into two groups, an early LLH group (ELLH group) and a recent LLH group (RLLH group), based on the surgical approach used for the left hepatic pedicle.

Results: A total of 72 cases of LLH (26 ELLH and 46 RLLH) were identified. The RLLH group exhibited a shorter median operative time, median length of hospital stay, and lower median blood loss compared to the ELLH group (182, 162.5–223.7 versus 232.5, 200–357.5 minutes, P < .01; 5, 4.2–7 versus 7, 6–8.7 days, P < .05; 150, 100–257.5 versus 300, 200–337.5 mL, P < .05, respectively). No perioperative mortality was observed.

Conclusions: This study confirms that our improved surgical technique for LLH is practical, safe, and effective. The main advantage of this method compared to other techniques is the possibility of attaining rapid and precise control of vascular inflow, thus facilitating LLH.

Single port laparoscopic liver surgery: A minireview

Nowadays, the trend is to perform surgeries with "scarless" incisions. In light of this, the single-port laparoscopic surgery (SPLS) technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages, as the only entry point is usually hidden in the umbilicus. The interest in "scarless" liver resections did not grow as rapidly as the interest in other scarless surgeries. Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrow incision with limited exposure. There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections (SPL-LR) for hepatocellular carcinoma or metastatic colorectal cancer. In addition, getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging. In this article, we reviewed the published literature to describe history, indications, contraindications, ideal patients for new beginners, technical difficulty, advantages, disadvantages, oncological concern and the future of SPL-LR.

Laparoscopic parenchymal preserving hepatic resections in semiprone position for tumors located in the posterosuperior segments

INTRODUCTION

All patients who underwent laparoscopic liver resections in the posterosuperior segments (LPSS) at our center were positioned in semiprone since August 2011. The aims of this study were to assess differences in perioperative outcomes between laparoscopic left lateral sectionectomies (LLLS) performed in supine position and LPSS in semiprone position.

METHODS

We reviewed our prospectively collected database of all liver resections performed between January 2012 and January 2015. LLLS and LPSS were compared with respect to demographics and perioperative outcomes.

RESULTS

Forty-five patients underwent LLLS (n = 20) or LPSS (n = 25). There were no differences in patient demographics or tumor diameter (p = 0.946). There were no conversions. Pringle maneuver was not used in both groups. There was no difference in peroperative central venous pressure (p = 0.511). The median operative time in the LLLS group was 100 min (60-260) and 160 min (95-270) in the LPSS group (p = 0.002) with median intraoperative blood loss in the LLLS group of 50 ml (0-550) versus a larger 150 ml (50-700) (p = 0.010) for patients receiving LPSS. No patients required transfusion. Intraoperative and postoperative complication rates were similar in both groups. Median hospital stay was 6 days in both groups (p = 0.554).

CONCLUSION

LPSS in semiprone can be performed with similar clinical outcomes as a minor laparoscopic liver resection except for longer operative time and larger intraoperative blood loss without the need for transfusion.

Learning curve of self-taught laparoscopic liver surgeons in left lateral sectionectomy: results from an international multi-institutional analysis on 245 cases

BACKGROUND

Laparoscopy was suggested as gold standard for left lateral sectionectomy (LLS), thanks to recognized benefits compared to open approach. Aim of this study was to define learning curve (LC) of laparoscopic LLS (LLLS) using operative time (OT) as tool to analyze outcome of procedures performed by four experienced surgeons. Reproducibility and safety of LC in LLLS among independent surgeons were also analyzed as essential features of "standard procedure" concept.

METHODS

LLLS performed by four experienced surgeons was collected. Multivariate analysis was carried out to screen factors affecting OT. A cumulative LC was created calculating median OT. Skewness of OT was analyzed, and ROC curve was carried out to identify the cutoff for LC. The impact of LC on outcomes (morbidity and mortality, blood loss, conversions, surgical margins and length of stay) was determined.

RESULTS

A total of 245 LLLSs were collected. Conversion rate was 1.2 %. Median OT was 141 min, blood loss 100 mL, morbidity 11.4 % and mortality 0.4 %. "Associated procedures" was the only independent factor affecting OT. The skewness of the OT was calculated, and the cutoff point for LC was determined after 15 LLLSs. LLLS performed during and after LC period had similar outcomes.

CONCLUSION

LLLS is feasible with low morbidity, mortality and conversion rate. LC in LLLS is shorter compared to minor liver resections. Furthermore, it is reproducible and safe since it does not negatively affect clinical outcome. A reproducible, safe and short LC contributes to considering laparoscopy as the gold standard approach to perform LLS.

Laparoscopic Hepatectomy for Liver Cancer

This chapter covers a range of important topics of laparoscopic hepatectomy as a novel approach toward treatment of liver cancer. Although laparoscopic hepatectomy was performed in a limited number of centers in the 1990s, technological innovations, improvements in surgical techniques and accumulation of experience by surgeons have led to more rapid progress in laparoscopic hepatectomy in the late 2000s for minimally invasive hepatic surgery. Currently, laparoscopic hepatectomy can be performed for all tumor locations and several diseases via several approaches. The laparoscopic approach can be applied to several types of resection, not only for tumors but also for liver transplantation, with equivalent or better results compared with those obtained with open surgery. Therefore, laparoscopic hepatectomy will become a standard procedure for treatment of liver cancer in the near future.

Italian experience in minimally invasive liver surgery: a national survey

This survey provides an overview about current spread of Minimally Invasive Liver Resection (MILR) in Italy. Primary endpoint was to assess evolution of MILR in recent years and its degree of application among centres with different experience in laparoscopic and hepatic surgery. A questionnaire with items describing activity MILR was sent to Italian surgical centers. Diagnosis, technical approaches, resection extent, devices and vascular control, reasons for conversion, morbidity and mortality were recorded. Level of expertise per centre was analysed in terms of learning curve acquisition and relationship with hepatobiliary background. 1497 MILRs from 39 centers (median 27 patients/center, range 1-145, period 1995-2012) were collected. Conversion rate was 10.7% (180 patients out of 1677, excluded from subsequent analysis), with bleeding representing most frequent cause of conversion (34.4%). Eleven centers completed learning curve, performing >60 MILR. Benign lesions were 27.5% and malignant 72.5%, with hepatocellular carcinoma being the most frequent indication. 92.6% of cases were performed with a totally laparoscopic technique (1.3% were hand-assisted, 1.9% single-port and 4.2% robotic). Minor resections accounted for 92.9% (left lateral sectionectomy resulted the most frequent procedure; 23.8%), while major resections represented 7.1%. Overall mortality was 0.2% (3 of 1497 patients) and morbidity 22.8%. Mean length of stay was 5 days. Correlation between MILR activity and a hepatobiliary background was not clear comparing MILR cases and liver resection volumes per center. MILR has been significantly widespread in Italy in recent years, with several centers having definitely completed the learning curve as attested by clinical results consistent with major series from the Western and Eastern countries. MILR programs in Italy seem to arise from both centers with specific hepatobiliary expertise and centers performing advanced general laparoscopic surgery.

Advances in reduced port laparoscopic liver resection

Reduced port surgery has been attracting attention in the field of minimally invasive surgery. Although the use of SILS is becoming widespread, technical difficulty has delayed its adoption for laparoscopic liver resection. Recently, advances in laparoscopic liver resection have been made in tandem with advances in surgical skill and devices. The main driver in conventional laparoscopic liver resection's evolution to become less surgically invasive seems to be single-incision laparoscopic liver resection (SILLR). To date, most reports on SILLR have been single case reports or case series. Only a few cohort studies on conventional laparoscopic surgery and SILLR have been conducted. Recent reports have described the use of SILLR for well-localized lesions and solitary tumors located in the anterolateral segments of the liver or left liver lobe, but its application remains limited to partial resection and left lateral sectionectomy. The feasibility and safety of SILLR have been demonstrated, but additional work is needed for standardization of the procedure.

Therapeutic advances: Single incision laparoscopic hepatopancreatobiliary surgery

Single-port laparoscopic surgery (SPLS) is proposed to be a step towards minimizing the invasiveness of surgery, and has since gained popularity in several surgical sub-specialties including hepatopancreatobiliary surgery. SPLS has since been applied to cholecystectomy, liver resection as well as pancreatectomy for a multitude of pathologies. Benefits of SPLS over conventional multi-incision laparoscopic surgery include improved cosmesis and potentially post-operative pain at specific time periods and extra-umbilical sites. However, it is also associated with longer operating time, increased rate of complications, and increased rate of port-site hernia. There is no significant difference between length of hospital stay. SPLS has a significant learning curve that affects operating time, rate of conversion and rate of complications. In this article, we review the literature on SPLS in hepatobiliary surgery - cholecystectomy, hepatectomy and pancreatectomy, and offer tips on overcoming potential technical obstacles and minimizing the complications when performing SPLS - surgeon position, position of port and instruments, instrument crossing position, standard hand grip vs reverse hand grip, snooker cue guide position, prevention of incisional hernia. SPLS is a promising direction in laparoscopic surgery, and we recommend step-wise progression of applications of SPLS to various hepatopancreatobiliary surgeries to ensure safe adoption of the surgical technique.

Intrahepatic glissonian approach for single-port laparoscopic liver resection

BACKGROUND

Minimal access surgery is moving toward reduced size and fewer ports. The aim of this article is to describe our experience with the intrahepatic Glissonian approach for single-port laparoscopic left lateral sectionectomy.

SUBJECTS AND METHODS

We have performed this procedure on 8 consecutive patients. A transumbilical incision is performed, and a single-incision platform is introduced. The operation begins with ultrasound examination of the liver. Intrahepatic Glissonian access of the portal pedicle from segments 2 and 3 is performed, and the pedicle is divided with a stapler. The liver is transected, and the left hepatic vein is divided with a stapler. A surgical specimen is retrieved through the single umbilical incision. No drains are left in place.

RESULTS

The median operative time was 68 minutes, and there was minimal bleeding. The median hospital stay was 1 day. Six patients were operated on for liver adenoma. There was no morbidity or mortality. During follow-up (median, 12 months), no patient developed incisional hernia. The cosmetic appearance of the incision was excellent in all cases.

CONCLUSIONS

Single-port laparoscopic left lateral sectionectomy is feasible and can be safely performed in specialized centers.

[First single-port laparoscopic liver resection in Brazil]

INTRODUCTION

Since the past decade, minimal access surgery is moving towards minimizing the surgical trauma by reducing numbers and size of the laparoscopic ports . A novel technique with a single-incision laparoscopic approach has been recently described.

AIM

To describe the single-port technique for laparoscopic liver resection.

TECHNIQUE

A transumbilical 3-cm skin incision is performed and a single-incision advanced access platform is introduced. Operation began with exploration of the abdominal cavity and ultrasound examination of the liver. Intrahepatic Glissonian access for retrieval of portal pedicles from segments 2 and 3 is performed. Vascular endoscopic stapler is used to divide segments 2 and 3 Glissonian pedicle. Liver is transected with harmonic scalpel and left hepatic vein is divided with stapler. Procedure is completed. Surgical specimen is retrieved through the single umbilical incision. No drains are left in place.

CONCLUSION

Single port laparoscopic left lateral segmentectomy is feasible and can be safely performed in specialized centers by skilled laparoscopic surgeons.

SILS hepatectomy for hepatic hydatid disease: a case report

Single-incision laparoscopic surgery (SILS) is being used with increasing frequency in the treatment of many conditions requiring surgery. Experience with SILS for hepatectomy is limited. This is one of the first reports of SILS hepatectomy in the treatment of hepatic hydatid disease. A 17-years-old female who has 89 × 59-mm cystic mass in the left lobe of the liver was admitted with abdominal pain persisting for several months. For treatment of the mass, SILS hepatectomy performed. Although complexity of the liver structure and the technical difficulties of SILS restrict its applications in hepatic surgery, the treatment of liver hydatid disease with SILS in selected patients is safe and efficient. Moreover, it allows a better cosmetic result and rapid recovery.

Laparoscopic left lateral sectionectomy as a training procedure for surgeons learning laparoscopic hepatectomy

BACKGROUND

Laparoscopic liver resection remains limited to a relatively small number of institutions because of insufficient hepatic and laparoscopic surgical experience and few training opportunities. The aim of this study was to assess the feasibility and safety of an improved laparoscopic left lateral sectionectomy technique as a training procedure for new surgeons.

METHODS

Twenty-four laparoscopic left lateral sectionectomies (LLLSs) were retrospectively reviewed. Patients were divided into 3 groups with 8 patients in each: those undergoing surgery by expert surgeons prior to 2008 (Group A); those undergoing surgery by expert surgeons after 2008, when a standardized LLLS technique was adopted (Group B); and those undergoing LLLS by junior surgeons being trained (Group C).

RESULTS

The median operative time was significantly shorter for Group B (103 min; range, 99-109 min) and C (107 min; range, 85-135 min) patients than for Group A (153 min; range, 95-210 min) patients. There were no significant differences in blood loss or hospital stay. In Groups B and C, no conversions to open laparotomy or complications occurred.

CONCLUSION

The standardized LLLS procedure was both safe and feasible as a technique for training surgeons in laparoscopic hepatectomy.

Single incision laparoscopic hepatectomy: Advances in laparoscopic liver surgery

BACKGROUND:

Laparoscopic liver surgery is now an established practice in many institutions. It is a safe and feasible approach in experienced hands. Single incision laparoscopic surgery (SILS) has been performed for cholecystectomies, nephrectomies, splenectomies and obesity surgery. However, the use of SILS in liver surgery has been rarely reported. We report our initial experience in seven patients on single incision laparoscopic hepatectomy (SILH).

PATIENTS AND METHODS:

From October 2010 to September 2012, seven patients underwent single-incision laparoscopic liver surgery. The abdomen was approached through a 25 mm periumbilical incision. No supplemental ports were required. The liver was transected using a combination of LigaSure™ (Covidien-Valleylab. Boulder. USA), Harmonic Scalpel and Ligaclips (Ethicon Endo-Surgery, Inc.).

RESULTS:

Liver resection was successfully completed for the seven patients. The procedures consisted of two partial resections of segment three, two partial resections of segment five and three partial resections of segment six. The mean operative time was 98.3 min (range: 60-150 min) and the mean estimated blood loss was 57 ml (range: 25-150 ml). The postoperative courses were uneventful and the mean hospital stay was 5.1 days (range: 1-13 days). Pathology identified three benign and four malignant liver tumours with clear margins.

CONCLUSION:

SILH is a technically feasible and safe approach for wedge resections of the liver without oncological compromise and with favourable cosmetic results. This surgical technique requires relatively advanced laparoscopic skills. Further studies are needed to determine the potential advantages of this technique, apart from the better cosmetic result, compared to the conventional laparoscopic approach.

Minimally invasive liver resection: robotic versus laparoscopic left lateral sectionectomy

BACKGROUND

The purpose of this study was to compare the clinical and economic outcomes of robotic versus laparoscopic left lateral sectionectomy (LLS).

METHODS

A retrospective analysis was made comparing robotic (n = 11) and laparoscopic (n = 18) LLS performed at the University of Pittsburgh Medical Center between January 2009 and July 2011. Demographic data, operative, and postoperative outcomes were collected.

RESULTS

Demographic and tumor characteristics of robotic and laparoscopic LLS were similar. There were also no significant differences in operative outcomes including estimated blood loss and operating room time. Patients undergoing robotic LLS had more admissions to the ICU (46 versus 6 %), increased rate of minor complications (27 versus 0 %), and longer lengths of stay (4 versus 3 days). There were no significant differences in major complication rates or 90-day mortality. The cost of robotic and laparoscopic LLS was not significantly different when only considering direct costs ($5,130 versus $4,408, p = 0.401). However, robotic LLS costs were significantly greater when including indirect costs, which were estimated to be $1,423 per robotic case ($6,553 versus $4,408, p = 0.021).

DISCUSSION

Robotic LLS yields slightly inferior clinical outcomes and increased cost compared to the laparoscopic approach.

Single-incision laparoscopic hepatectomy for benign and malignant hepatopathy: initial experience in 8 Chinese patients

BACKGROUND

The single-incision laparoscopic surgery (SILS) technique has been used in many surgical procedures, but there are few reports regarding liver surgeries. The purpose of this study was to perform single-incision laparoscopic hepatectomy (SILH) using standard laparoscopic instrumentation in 8 Chinese patients. The advantages and prospective future applications of SILH are also described.

METHODS

Selected patients were hospitalized between December 2009 and November 2011. The procedure was accomplished through a 2.5-cm transabdominal wall incision using a laparoscope and 2 other instruments without the assistance of any articulating instruments or single multiport trocar.

RESULTS

All procedures were successfully performed without the need for supplemental trocars. Postoperative pathological examinations were supportive of the preoperative diagnoses. No complications such as perioperative hemorrhage or infections occurred.

CONCLUSION

SILH appears to be a safe approach and the results are cosmetically favorable. The accumulation of SILH experience and the development of instrumentation are needed for extensive use of this technique in hepatectomies.

Laparoscopic splenectomy and esophagogastric devascularization is a safe, effective, minimally invasive alternative for the treatment of portal hypertension with refractory variceal bleeding

Open splenectomy and esophagogastric devascularization (OSED) is a typical surgery for portal hypertension. Because of the high morbidity associated with it, it is desirable to develop a minimally invasive alternative. To investigate the safety and effect of laparoscopic splenectomy and esophagogastric devascularization (LSED), we performed LSED for 24 patients suffering from portal hypertension with refractory variceal bleeding while conducting OSED for 30 patients. The perioperative data and follow-up results were analyzed. Operation times were similar in both groups. Less intraoperative blood and faster return of gastrointestinal function were found in the LSED group. The LSED group had lower levels of alanine aminotransferase, aspartate aminotransferase, and total bilirubin after surgery. In both groups, the levels of platelet count, white blood cell count, or hemoglobin were increased after operation dramatically. During the follow-up period (range = 3-36 months), no patient had recurrent hypersplenism or variceal bleeding. Hence, LSED is a safe and minimally invasive intervention for portal hypertension with refractory variceal bleeding.

A novel extra-glissonian approach for totally laparoscopic left hepatectomy

INTRODUCTION

We describe a novel extra-glissonian approach (EGA) for totally laparoscopic left hepatectomy. Published techniques for totally laparoscopic left hepatectomy generally involve the selective ligation of the vascular and biliary elements of the left pedicle. The laparoscopic dissection of these structures can be tedious, difficult, and dangerous. The EGA has proven useful in open surgery for major hepatectomies. We feel that this approach could be even more useful in the laparoscopic context.

METHODS

We describe an extra-glissonian laparoscopic technique in which the left pedicle is isolated extraparenchymally, detaching the left hilar plate, with particular attention to preserving the branch for segment I. The left portal triad is encircled with a cotton tape and transected with an endostapler. This is performed totally extraparenchymally without damaging the surrounding parenchyma.

RESULTS

This EGA technique for laparoscopic left hepatectomy follows by laparoscopy the same steps and recommendations that make the EGA safe and effective in open surgery.

CONCLUSIONS

The EGA for LLH can be performed as described in open surgery, therefore offering the same advantages.

Laparoendoscopic single site (LESS) surgery for left-lateral hepatic sectionectomy as an alternative to traditional laparoscopy: case-matched analysis from a single center

BACKGROUND

Laparoscopy is considered the "gold standard" to perform left-lateral sectionectomy with results identical to those of open surgery, yielding decreased postoperative pain and disability, reduced hospital stay, and shortened patient recovery time. As the emphasis on minimizing the invasiveness of surgical techniques continues, laparoendoscopic single site (LESS) surgery is quickly evolving. The purpose of this study was to compare the results of laparoscopic left-lateral sectionectomy performed using the traditional approach or LESS approach with a case-matched analysis for tumor size, type of resection, and surgical indications.

METHODS

Thirteen patients who underwent LESS left-lateral sectionectomy are considered the study group (LESS group) and compared with 13 patients who underwent left-lateral sectionectomy with traditional laparoscopic approach (conventional group).

RESULTS

There were no significant differences between groups for length of surgery (165 min in conventional group vs. 195 min in LESS group), blood loss (150 mL in conventional group vs. 175 mL in LESS group), conversion to open surgery, histological tumor exposure, and requirements of postoperative analgesics. One patient in the LESS group died of cardiac failure due to an unknown severe aortic valve stenosis. No differences were recorded for postoperative complications (23.1% in both groups) and median length of postoperative stay (4 days in both groups).

CONCLUSIONS

For left-lateral hepatic sectionectomy, LESS surgery is technically feasible and as safe as traditional laparoscopic surgery in terms of intraoperative and postoperative results, even though requiring both hepatobiliary and laparoscopic technique experience.

Long-term results of laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma: a case-matched analysis

BACKGROUND

Laparoscopic hepatectomy (LH) is established as a safe and feasible treatment option for liver tumors. However, whether the adoption of laparoscopic approach for malignant tumors, such as hepatocellular carcinoma (HCC), will compromise the long-term result is still unknown. This study was designed to evaluate the long-term results of LH compared with a cohort of case-matched open hepatectomy (OH).

METHODS

Thirty-three patients who underwent LH for HCC in our institution between June 2004 and March 2010 were recruited. A group of 50 patients who underwent OH for HCC during the same period was identified by matching to magnitude of operation, size of tumor, site of tumor, and the absence of concomitant local ablation or major procedure. The perioperative outcomes, disease recurrence, and survival of the two groups of patients were determined and compared.

RESULTS

LH resulted in less operative complications (6.1% vs. 24%, P = 0.033) and shorter median hospital stay (5 vs. 7 days, P < 0.0005) but required longer operative time compared with OH (225 vs. 195 min, P = 0.019). There was no difference between LH and OH in recurrence rate (45.5% vs. 38%, P = 0.499). The 1-, 3-, and 5-year overall survival were 86.9%, 81.8%, and 76% for LH and 98%, 80.6%, and 76.1% for OH respectively (P = 0.646). The 1-, 3-, and 5-year disease-free survival were 78.8%, 51%, and 45.3% for LH and 69.2%, 55.9%, and 55.9% for OH, respectively (P = 0.849).

CONCLUSIONS

Compared with OH, LH for HCC has similar long-term outcomes, but it has short-term advantages of less operative complications and shorter hospital stay.

Liver Surgery for Hepatocellular Carcinoma: Laparoscopic versus Open Approach

In this study, we try to compare the benefit of laparoscopic versus open operative procedures. Patients and Methods. One hundred and sixteen patients underwent laparoscopic liver resection (LR) and another 208 patients went for open liver resection (OR) for hepatocellular carcinoma (HCC). Patients' selection for open or laparoscopic approach was not randomized. Results. The CLIP score for LR and OR was 0.59 ± 0.75 and 0.86 ± 1.04, respectively, (P = .016). The operation time was 156.3 ± 308.2 and 190.9 ± 79.2 min for LR and OR groups, respectively. The necessity for blood transfusion was found in 8 patients (6.9%) and 106 patients (50.9%) for LR and OR groups. Patients resumed full diet on the 2nd and 3rd postoperative day, and the average length of hospital stay was 6 days and 12 days for LR and OR groups. The complication rate and mortality rate were 0% and 6.0%, 2.9% and 30.2% for LR and OR groups, respectively. The 1-yr, 3-yr, and 5-yr survival rate was 87.0%, 70.4%, 62.2% and 83.2%, 76.0%, 71.8% for LR and OR group, respectively, of non-significant difference. From these results, HCC patients accepted laparoscopic or open approach were of no significant differences between their survival rates.

Resection margin in laparoscopic hepatectomy: a comparative study between wedge resection and anatomic left lateral sectionectomy

BACKGROUND

Experience from open hepatectomy shows that anatomic liver resection achieves a better resection margin than wedge resection. In recent years, laparoscopic hepatectomy has increasingly been performed in patients with liver pathology including malignant lesions. Wedge resection (WR) and left lateral sectionectomy (LLS), which also represent non-anatomic and anatomic resection respectively, are the two most common types of laparoscopic hepatectomy performed. The aim of the present study was to compare the two types of laparoscopic hepatectomy with emphasis on resection margin.

METHODS

Between November 2003 and July 2009, 44 consecutive patients who underwent laparoscopic hepatectomy were identified and retrospectively reviewed. The WR and LLS group of patients were compared in terms of operative outcomes, pathological findings, recurrence patterns and survival.

RESULTS

Out of the 44 patients, 21 underwent LLS and 23 a WR. The two groups of patients were comparable in demographics. The two groups did not differ in conversion rate, blood loss, blood transfusion, mortality, morbidity and post-operative length of stay. The LLS group patients had significantly larger liver lesions, wider resection margin and less sub-centimetre margins. In patients with malignant liver lesions, there was no difference between the two groups in incidence of intra-hepatic recurrence and 3-year overall and disease-free survival.

CONCLUSION

Operative outcomes are similar between laparoscopic WR and LLS. However, WR is less reliable than LLS in achieving a resection margin of more than 1 cm. Larger studies involving more patients with longer follow-up are warranted to determine the impact of the resection margin on intra-hepatic recurrence and survival.